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Peripheral Vascular Examination
Dr. Gary Mumaugh – Western Physical Assessment
Competencies
1. Inspection of upper extremity for:
• size
• symmetry
• swelling
• venous pattern
• color
• Texture
• nail beds
Competencies
2. Inspection of lower extremity for:
• size
• scars
• symmetry
• color
• swelling
• nail beds
• rashes
• ulcerations
• texture
• venous enlargement
• unusual pigmentation
• hair distribution
Competencies
3. Palpate these pulses:
• carotid
• brachial
• radial
• ulnar
• femoral
• popliteal
• dorsalis pedis
• posterior tibial
Competencies
4. Technique for detecting edema
5. Detect and describe varicosities
6. Perform an Allen test
7. Assess blood pressure
8. Assess capillary refill
Health History
• Common or concerning symptoms
• Pain in arms or legs
• Intermittent claudication
• Cold, numbness, pallor in legs, hair loss
• Swelling in calves, legs, or feet
• Color changes in fingertips or toes in cold
weather
• Swelling with redness or tenderness
Health History
• P.A.D Peripheral arterial disease
• Aka - Intermittent claudication
• Ask “Have you ever had any pain or cramping
in the legs when walking or with exercise?”
“Does the pain get better with rest?”
• Most patients with P.A.D. have no symptoms or
non-specific symptoms
• Exercise-induced calf pain that causes the
patient to stop exercise and experience pain
relief in 10 minutes is present in only 10% of
affected patients
• Screen for subclinical P.A.D.
Health History
• Arterial spasm of fingers and toes
• Ask “Do your fingertips or toes ever
change color in cold weather or when you
handle cold objects?”
• Venous peripheral vascular disease
• Swelling of feet and legs
• Ask about ulcers on lower legs, often near
ankles
Arteries
• Arterial pulses are palpable when an artery lies close to the body surface
• In the upper extremity the ulnar pulse may be obscured by overlying tissues
Veins
• Deep veins carry 90% of the venous return
from the lower extremity
• well supported by surrounding tissues
• Superficial veins are located subcutaneously
• Supported poorly
Veins
Veins
• Deep, superficial and communicating veins all have one way valves
• Blood flows from the superficial to deep system toward the heart
• Muscles contract and blood is squeezed upward against gravity
• Competent valves keep it from falling back again
Fluid Exchange
• Blood circulates from arteries to veins through the
capillary bed
• Dynamic equilibrium between vascular and
interstitial spaces
• Maintains dynamic equilibrium between vascular
and interstitial space
• Higher blood pressure in arteries
• Lower osmotic attraction in tissue spaces
• Opposed by hydrostatic pressure in spaces
• Blood pressure drops at venous end
• Osmotic pressure increases plasma pressure
• Pulls back fluid into vascular tree
• Lymphatics pull up excessive fluid
Inspection: Upper Extremity
Size and Symmetry
Inspection: Upper Extremity
Swelling
Inspection: Upper Extremity
Venous Pattern
Inspection: Upper Extremity
Color
Inspection: Upper Extremity
Texture
Inspection: Upper Extremity
Nail beds
Inspection: Lower Extremity
Size and Symmetry
Inspection: Lower Extremity
Swelling
Inspection: Lower Extremity
Venous Enlargement
Inspection: Lower Extremity
Pigmentation, Scars
Inspection: Lower Extremity
Rashes, Ulcerations
Inspection: Lower Extremity
Color
Inspection: Lower Extremity
Texture
Inspection: Lower Extremity
Nail beds
Inspection: Lower Extremity
Hair Distribution
Pulses
• Use your fingertips NOT your thumbs
• Firm even pressure
• Be sure the pulsations you are perceiving are
the patient’s and not your own
• NEVER palpate both carotids at once
Pulses
• Described as :
• Increased
• Normal
• Diminished
• Absent
• Aneurysmal
Pulses
• Diminished or absent pulse indicates partial
or complete occlusion proximally
• Example: If femoral pulse absent
occlusion is aortic or iliac and all pulses
distally are affected
• Widened pulse suggests aneurysm
Arterial Occlusion
• Most common cause is arteriosclerosis
obliterans in which fatty plaques impede
blood flow
• Most often occurs in the thigh
• Symptoms are cold, pale, pulseless extremity
Arterial Occlusion
• Decreased or absent foot pulses suggest
occlusive disease of the lower popliteal artery
• Commonly seen in diabetics
Carotid pulse
• Inspect the neck for
pulsations just
medial to the SCM
• Place 2nd and 3rd
fingers on lower
third of neck
• Press posteriorly
and feel for pulse
Brachial Pulse
• Patient’s arm should
rest with elbow
extended palm up
• Use 2nd and 3rd
digits of opposite
hand
• Cup your hand
under the patient’s
elbow
• Feel for pulse just
medial to biceps
tendon
Radial Pulse
• Use pads of your
fingers on the flexor
surface of the wrist
laterally
• Partially flexing the
patient’s wrist may
help
Ulnar Pulse
• Using the pads of
your fingers feel for
the pulse deeply on
the flexor surface of
the wrist medially
Femoral Pulse
• Press deeply below
the inguinal ligament
and about midway
between the anterior
superior iliac spine
and the symphysis
pubis
Popliteal Pulse
• Patient should be
prone
• Flex the knee to 90o
• Let the leg rest
against you
• Use your thumbs to
press deeply into
the popliteal fossa
Dorsalis Pedis Pulse
• Feel the dorsum of
the foot just lateral
to the extensor
tendon of the great
toe
• If no luck, try more
laterally
Posterior Tibial Pulse
• Curve your fingers
behind and slightly
below the medial
malleolus of the
ankle
Grading Amplitude of Arterial
Pulses
• 3 + Bounding
• 2 + Brisk, expected, normal
• 1 + Diminished, weaker then expected
• 0 Absent, unable to palpate
Edema
• Press firmly but
gently for 5 seconds
over:
– Dorsum of each foot
– Behind medial
malleolus of each
ankle
– Over each shin
Edema
• Pitting is a depression caused by the
pressure of your fingers
• Edema is graded on a 5 point scale from
trace to +4
Edema
• Trace: minimal edema of foot
• +1: edema of foot
• +2: edema to ankle
• +3: edema halfway up shin
• +4: edema to knees
Edema
• Possible causes:
• Recent deep venous thrombosis
• Chronic venous insufficiency
• Incompetent venous valves
• Lymphedema
Varicosities
• You can map the course of varicosities by transmitting pressure waves in filled veins
• Patient must stand
• Place fingers gently on vein
• Compress sharply
Lower Extremity: Pathology
• Local swelling, redness, warmth and a
palpable cord suggest superficial
thrombophlebitis
• Brownish color or ulcers just above the ankle
suggest chronic venous insufficiency
• Thickened skin occurs in lymphedema
Allen Test
• Used to evaluate arterial supply to the hand
• Must be done to assess ulnar artery patency
before puncturing radial artery for blood
draws or line placement
• Performing a Modified Allen Test
Allen Test
• Palms up
• Occlude radial and
ulnar arteries
• Make tight fist
• Release fist and
hand is pale
• Open one artery and
hand turns pink
Blood Pressure
• Learned in cardiovascular exam
• Practice again today with special attention to
technique in relation to pulses of upper
extremity
Capillary Refill
• Used to assess ability of capillaries to refill with blood when emptied
• Normal is < 2 seconds
• Must be performed on clear nails with NO polish, blood, or fungus
• Press on end of nail until nail bed becomes pale
• Release and assess time to turn pink
• Capillary Refill
Capillary Refill
Special Techniques
• If chronic arterial insufficiency is suspected
(pain or diminished pulses), check for
postural color changes
• Raise both legs to 60 degrees until
maximum pallor of feet develop (usually
within one minute)
• Ask patient to sit up with legs dangling
• Compare both feet
• Normally returns to pink in less than 10
seconds
• Filling of veins takes about 15 seconds
Special Techniques
• Mapping varicose veins
• Map out the course & connection of varicose
veins by transmitting pressure waves along the
blood filled veins
• Patient in standing position
• Press veins at two points
• Press sharply & feel the pressure at the top end
• A palpable pressure wave suggests two points
are connected (patent)
• Wave may be transmitted downwards but not
easily
Special Techniques
Trendelenburg Test
• Competency of Venous Valves
• Patient supine – elevate leg 90 degrees to empty veins
• Occlude greater saphenous vein in upper thigh
• Ask patient to stand up and keep vein occluded
• Watch for venous filling
• Normally fills from below upwards and takes about
35 seconds as blood flows from capillary bed into
veins
• 20 seconds after standing release the compression
• Watch for any additional filling – normally none
• Sudden retrograde filling suggests incompetent
valves
Question
• A patient you are seeing complains of a sore on
his lower leg that does not seem to get better.
Based on examination findings, you suspect
venous insufficiency. Which of the following
clinical findings would suggest venous
insufficiency as the cause of his problems?
a) Leg discomfort is exacerbated by using
b) Hyperpigmentation is present around the
lower calf
c) Ulcers are present on the medial ankle
d) Affected leg feel warm to the touch
All are correct
• Your patient complains of severe pain in her
right foot. Based upon your examination
findings, you suspect arterial insufficiency.
Which of the following clinical findings would
suggest your diagnosis?
a) Brisk posterior tibial and dorsalis pedis
pulses
b) Pallor of the foot with elevation
c) Pitting edema of the lower leg
d) Warmth of the right foot
a) The pulses would be decreased
b) Pallor of the foot on elevation
c) There would be no pitting edema
d) Right foot would be cool, not warm
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